Page 44 - 2023-small-group-brochure

Platinum health plans
Benefits per contract year1
Personal Choice PPO Platinum HSA — 504 $1,800/100%
You pay in-network You pay out-of-network7
$1,800/$3,600 $10,000/$20,000
0% 50%
$7,450/$14,900 coinsurance, copays, and ded $20,000/$40,000 coinsurance and ded
Preventive services8
0% no ded 50% no ded
0% no ded N/A
$750 no ded 50% no ded
Physician services
0% after ded/0% after ded 50% after ded/50% after ded
0% after ded/0% after ded 50% after ded/50% after ded
0% after ded 50% after ded
0% after ded Not covered
0% after ded 50% after ded
0% after ded9 50% after ded9
Hospital/other medical services
0% after ded/0% after ded9 50% after ded/50% after ded9
0% after ded 50% after ded
0% after ded 50% after ded
0% after ded 0% after in-network ded
0% after ded/0% after ded 50% after ded/50% after ded
0% after ded/0% after ded 50% after ded/50% after ded
0% after ded/0% after ded 50% after ded/50% after ded
0% after ded/0% after ded 50% after ded/50% after ded
0% after ded 50% after ded
0% after ded/0% after ded 50% after ded/50% after ded
0% after ded 50% after ded
0% after ded/0% after ded 50% after ded/50% after ded
0% after ded/0% after ded 50% after ded/50% after ded
Prescription drugs16, 17, 19
Integrated Integrated
$3 after ded 50% after ded
$10 after ded 50% after ded
$60 after ded 50% after ded
$100 after ded 50% after ded
50% after ded up to $1,000 max per fill Not covered
Vision and dental23, 28, 32
$0 no ded Not covered
$0 no ded Not covered
Allowance up to $130 for frames or contact lenses; up to $180 frame allowance at Visionworks stores
Not covered
Integrated Not covered
0% no ded Not covered
0% after ded Not covered
Deductible, individual/family
Coinsurance
Out-of-pocket maximum, individual/family includes:
Preventive care for adults and children
Preventive colonoscopy for colorectal cancer screening — Preventive Plus providers Preventive colonoscopy for colorectal cancer screening — hospital-based
Primary care visit — office/virtual care Specialist visit — office/virtual care
Retail clinic
Virtual care (from designated virtual provider)† Urgent care
Spinal manipulations (20 visits per year)/Acupuncture§ (18 visits per year) Physical/Occupational therapy — (30 visits per year) — freestanding/hospital-based
Inpatient hospital services (includes maternity)
Inpatient professional services (includes maternity) Emergency room
Routine radiology — freestanding/hospital-based
MRI/MRA, CT/CTA/PET scan — freestanding/hospital-based Biotech/Specialty injectables — home, office/outpatient Infusion — home, office/outpatient
Durable medical equipment/Prosthetics
Outpatient mental health and substance abuse — office visit/all other Inpatient mental health and substance abuse
Outpatient surgery — ambulatory surgical facility/hospital-based Outpatient lab/Pathology — freestanding/hospital-based
Rx deductible (individual/family) Low cost generic18
Retail generic18
Retail preferred brand18
Retail non-preferred drug18 Specialty drug
Pediatric routine eye exam24, 25 and eyewear (glasses or contacts)24, 26 Adult routine eye exam25
Adult eyewear (glasses or contacts)27
Pediatric dental deductible (per individual)29 Pediatric exams and cleanings29, 30
Pediatric basic, major, and orthodontia services29, 31
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Preferred: Copay plans | Classic: Coinsurance/deductible plans | Secure: Copay/deductible plans
Footnotes begin on page 72 | ded = Deductible